Influenza and pneumococcal diseases cause thousands of needless deaths annually in the US, with greater mortality from these illnesses among underserved minorities. Better tools to improve adult vaccination rates, particularly in minority populations, are needed. A proven, but underutilized vaccination facilitator is a standing order program (SOP) in which an eligible patient can receive immunizations from nursing staff without a specific physician order. We developed a locally successful approach using tailored interventions that included SOPs, to increase vaccination rates in inner-city health centers and eliminate racial disparities. But this approach has not been updated recently nor tested nationally. Based on a decade of research on barriers and facilitators of vaccination, we believe that continued progress requires a combination of office system changes including SOPs and patient messages. From our national survey of primary care physicians about facilitators of and barriers to SOPs for adult immunization, we developed and pilot-tested an expert reviewed toolkit to facilitate SOP adoption and increase vaccination rates. We propose to enhance the toolkit with a Practice Transformation Dashboard, add Tdap, and expand related online training materials, shaped by input from the community and a national advisory board. The purpose of this enhancement process is to optimize the Reach, Adoption, Implementation and Effectiveness of the toolkit and training materials. Components include an immunization champion, feedback, motivation, and patient reminders. To rigorously test it, we will conduct an intensive randomized cluster trial of the 4 Pillars SOP Toolkit in primary care practice networks with EMRs, aiming to increase vaccination rates by 10%-20% and to eliminate racial disparity; evaluate the intervention using the RE-AIM framework, and determine Maintenance in subsequent years. Together with the AMA and using lessons learned from the trial, conduct a national before-and-after trial of the toolkit, using an intensity level consistent with AMA's practice-improvement CME and evaluate it, using the RE-AIM framework. Finally, we will determine the potential translatability and public health impact of the intervention through modeling and cost-effectiveness analyses. PUBLIC HEALTH RELEVANCE: A proven, but underused, facilitator of immunization is a standing order program (SOP). We will revise an existing SOP toolkit and conduct an intensive randomized cluster trial of the SOP toolkit in primary care practice networks with EMRs. Using lessons learned from that trial, we plan a national before and improvement CME.